Personal reflections, comment, discussion by and for doctors working in Aboriginal Medical Services or those who want to understand their work better.

Wednesday, February 5, 2014

Should we be doing health assessments?

I was
recently interviewed for an Australian Doctor item on health assessments, after
I’d been involved in a Twitter discussion. I thought I’d set out
my thinking and links to the evidence I’m using. I do need to point out that
these are my personal views, and don’t represent the policy of any of the
organisations I work for.

The
evidence is not as strong as you might think. First up was this study which
caused some ripples in the UK, though not really in Australia. It’s a
systematic review done by the Cochrane Collaboration, so is pretty much gold
standard in the expertise of performing this sort of research. And this sort of
research – that is, a systematic review - is the most reliable in giving
trustworthy answers. They hunted down all the studies ever done to answer this
question, and discovered that doing health checks didn’t help people live
longer, and didn’t reduce people’s diseases. In fact, they were diagnosed
earlier, and so lived more of their life with a diagnosis, without getting
benefit from this. It also looked like people had just as many
admissions to hospital, disabilities, as much worry, the same number of visits
to the physician, and no fewer absences from work, though these findings were
less clear.

Shortly after this, another study from Australia came along.
They wondered if the outcomes of health checks were better for those performed
in General Practice. They used the same systematic review methodology, where
they tried to find all the research that had been done on this. They found that
there were improvements in total cholesterol, body mass index and systolic and
diastolic (that is the top and bottom) blood pressure figures. However, these
improvements were very small – the authors say that they were statistically
significant, which means that these results are probably not a chance finding.
However, it is likely that a change of 0.13mmol/L in cholesterol, and 0.45kg.m2
does not make a difference in real life. This result has been reported asreassuring us GPs that it is worth us doing health assessments after all. I’m
not so sure. There is no evidence of making people live longer in these
studies, and there is even a suggestion that doing a health assessment
increases your likelihood of dying of cardiovascular disease – another
statistically significant result.

At face value, the evidence would indicate that we are
certainly not saving any lives by doing health assessments, we may be labelling
people with pathology for more of their lives, without any attendant benefits,
and this may even be an intervention that gives people heart attacks or strokes
earlier!

There is an argument to be made that in a population that
have a higher risk of cardiovascular disease, such as Aboriginal and Torres
Strait Islander people (though not only that group), there will be more benefit
from doing health assessments. That may well be true, but there is no evidence
at all either way at the moment – the best we have is what I have described
above. This means by making this argument, we are entering a completely
evidence-free zone. We may well be doing harm without realising it. Usually in
medicine we are cautious about using an intervention widely if there is no
evidence that it is beneficial. This would not be the first time that a
combination of optimism and “common sense” that something ought to work has
trumped the lack of evidence.

I’m not a complete nihilist, though, and I do think there is
a way forward.

First, let’s note that health checks don’t appeal to
everybody. This systematic review shows that those who are least likely to
attend health checks are men, people without much money, people who aren’t
white, and less well educated. In other words, those who most need them. It may
be that in the field of Aboriginal and Torres Strait Islander Health we have
come up with a mechanism that intuitively appeals to those developing the
system but not to those using it.

The alternative approach is to build on the strengths of
General Practice and Primary Care. 85% of people in Australia have seen their
GP in the previous year, and the average number of visits is 5 or 6 each year.
Julian Tudor Hart described anticipatory care, where the relationship developed
and the series of visits over time meant that preventative activities could be
performed in this context. He was the first GP in the world to know the blood
pressure of every one of his patients. The two approaches, health checks and
anticipatory care, were compared in Scotland. This is not an outcomes study, but
we do know the outcomes for general health checks (see above) and we also know
the outcomes for many of the individual preventive activities. The ones
recommended are documented in the RACGP Red Book, and for Aboriginal and Torres
Strait Islander people in the National Guide to a Preventive Health Assessment
by RACGP and NACCHO. (Declaration – I was
on the editorial panel of this guideline and wrote the mental health chapter).

The solution, I think, is to promote the completion of
individual evidence based preventive activities in the context of a long term
therapeutic relationship. The Kanyini Vascular collaboration audit showed that this is already happening - cardiovascular disease preventive activity was occurring at the same level as in non-Indigenous people, but the number of health assessments billed was very low. Behaviour changes and referrals are more
likely to be performed, as the GP and Primary Care team can keep on following
up. Ideally, Medicare would pay at the completion of the recommended
activities, whether this was in a single consultation or over many. (The Diabetes PIP Cycle of care is already paid in this way (PDF)). Granted, the evidence
for this approach is limited. But the best evidence we have for the alternative
shows that it might be harmful. Clinicians are being asked to perform money-raising interventions, which services are measured on, and potentially doing harm in the process.

3 comments:

This is a great reflective article Tim, and I agree with completely. The evidence for regular health assessments on well people is rather underwhelming. As such, I think we need to approach any major recommendation for change in clinical practice in this direction critically.

I support entirely the notion that we need to focus on relationship building in routine general practice. I concur that there is definitely a risk that this process may well be impaired by long and unwieldy health assessments. Moreover, I worry that the technical practice of gathering health data will be perceived as "healthful behaviour" by patients, and "health promotion" by practitioners - potentially supplanting patient-doctor interactions that meaningfully have an impact on health (e.g., focussed SNAP discussions, psychosocial counselling, etc.)

We perform only aged care health assessments in our practice and only on those at home that we deem suitable as there seems no point in assessing someone who is out most of the day living life to the full. consequently by triage we are able to institute social support such as Aged Care packages, check the home based pharmacy cabinet, and the personal care alarms that many elderly patients living alone are sometimes unaware of. By selecting out these patients and because we know them well we are able to institute social support and community services that benefit our patients. Strictly speaking this is not a disease focussed activity and I am yet to diagnose anything new or astounding via a health assessment. However by seeing our selected (by Drs and nurses) patients we have been able to support them in their home environments more safely. As you say Tim and Michael, that the patients who refuse this home based activity are usually the ones most in need of support or most at risk of failing at home. We do not drive these assessments on an income generating premise but on a professional basis of concern. I am sure I therefore do not earn as much money as I could which is another discussion on the gaming of the system of medicare and its weighting of item numbers.

Thanks KP,I think you raise an important point, here. Mortality and morbidity are not the only important outcomes. Health assessments in the elderly are as much about identifying social functioning and quality of life issues - can someone cook safely, manage the stairs, get to the shops. These have a bigger impact on people as to whether their statin should be stopped or started. (It's a slightly different population, though, to those in the systematic reviews quoted above, which don't look at elderly people). The imperative, however, is that if we are identifying these problems, we also need local services to solve them. It's not as sexy as a new cancer hospital, but local, affordable access to occupational therapy, community nursing, meals on wheels, social services etc. is crucial if we are not to leave people languishing. Perhaps Health Assessment as advocacy tool...?